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Emerging adult college students: An analysis of student behavioral health, academic outcomes, and predictors of behavioral health service receipt Dissertation Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in the Graduate School of The Ohio State University By Tori Negash, MSW Graduate Program in Social Work The Ohio State University 2018 Dissertation Committee Audrey Begun, PhD, Advisor Kathryn Maguire-Jack, MSW, MPA, PhD Joseph Guada, PhD 1 Copyrighted by Tori Negash 2018 2 Abstract The emerging adult population, individuals between the ages of 18-29, has grown to 53.7 million in the United States (U. College students form a significant subset of this population, with 29 percent enrolled at a college or university (National Center for Education Statistics [NCES], 2015). One in three emerging adults will experience some form of mental health disorder (Eisenberg, Hunt, Speer & Zivin, 2011; Lipson, Gaddis, Heinze, Beck & Eisenberg, 2015) and the prevalence of substance use disorders is higher than any other age group (Substance Abuse & Mental Health Services Administration [SAMHSA], 2005). Emerging adult college students with behavioral health concerns face a myriad of challenges that include negative implications for education (Arria et al., 2013; Eisenberg, Golberstein, & Hunt, 2009; Eisenberg, Hunt, Speer, & Zivin, 2011; Sontag-Padilla et al., 2014), long-term health (Eisenberg, Hunt, Speer, & Zivin, 2011), and socioeconomic status (Wang et al.

Despite these challenges, few emerging adults receive help for their behavioral health concerns (Kessler et al., 2007; Lipson, Gaddis, Heinze, Beck, & Eisenberg, 2015; SAMHSA, 2012; Wang et al. Few researchers have examined this phenomenon, but some evidence shows that institutional and individual-level characteristics may play a role (Cadigan, Lee, & Larimer, 2018; Dunbar, Sontag-Padilla, Ramchand, Seelam, & Stein, 2017; Eisenberg, Hunt, Speer, & Zivin, 2011; Miller et al. ii The aims of the Emerging Adult Behavioral Health (EABH) study were to (1) evaluate the association between behavioral health service use and academic outcomes among emerging adult college students; and (2) determine if emerging adult college students’ decisions to use or not use behavioral health services are associated with specific student- or institution-level characteristics. Using secondary data from the 2015- 2016 Healthy Minds Study (HMS), the EABH study employed a combination analyses, including binomial logistic regression and hierarchical generalized linear modeling (HGLM), to examine the relationships between grade point average (GPA), service locations, individual- and institutional-level characteristics, and the use of behavioral health services among 22,800 emerging adult college students.

The results of the EABH study showed that 34.2 percent of students with behavioral health concerns used services. Mental health concerns were the most prevalent type experienced; students with co-occurring conditions reported the highest rate of service use. Off-campus services, from a provider in a student’s hometown or other location, were most often used. There was an inverse relationship between GPA and use of services.

Several student-level characteristics were related to service use, including race and/or ethnicity, year in school, type of behavioral health diagnosis, prior diagnosis, informal help-seeking, gender identity, sexual orientation, and residential status. Three institution-level variables were related to service use: religious-affiliation, enrollment size, and graduation rate. The EABH study confirmed both the high prevalence rates of behavioral health concerns and low rates of service use cited previously. In addition to expanding the student-level characteristics analyzed, the EABH study explored the impact of behavioral iii health status (e.

type of concerns) and service use on academic outcomes; the examination of institutional characteristics in this context was the most thorough, to date. Future research should investigate other student-level predictors of service use, such as barriers to help-seeking, measures of socioeconomic status, campus climate, sense of belonging, and student stress. Exploring the same institution-level characteristics with new schools would contribute valuable information about their viability as predictors of service use. iv Dedication To each person who believed in me along the way – for giving me the confidence to believe I could and the strength of will to finish.

v Acknowledgments Merely saying “thank you” seems an inadequate way to express my gratitude to the individuals mentioned here, but it will have to do. First, I would like to thank my advisor, Audrey Begun, who always pushed me to be better, regardless of what I set out to achieve. Thank you for giving so much through your advocacy and mentorship; I will always be grateful. Second, I would like to thank Katie Maguire-Jack.

Since my first day on the OSU campus, you have made me feel like I belong. You walked alongside me as I traversed the path from student to scholar, teaching me the best parts of mentorship, scholarship, and collegiality. You were always there with encouraging words, advice, support, opportunities for growth, humor, and friendship. Working with you over the past five years has been a blessing; I will never forget the example you set as my mentor.

To my husband, Neamen: thank you for believing in me from the very beginning of our relationship. Any time I doubted myself, you were there to tell me just the right thing to get me back on track. Thank you for being my partner in life, for your love and understanding, your sense of humor, and your unwavering support. To my parents, Scott and Beth, and my sister Dani: thank you for your love, support, advice, pep talks, and reminders to “just do my best.” You have always believed in me, and because of that, I have believed in myself.

It is an honor to call you my family, and I will always be vi grateful for your role in this journey. Without your support, I never would have believed this was possible. Finally, I would like to acknowledge and thank both the Healthy Minds Network for Research on Adolescent and Young Adult Mental Health at the University of Michigan for granting me access to the Healthy Minds Study (HMS) data, and the students who took the time to participate in the study. Sociology, Indiana University 2010 Certificate in Social & Cultural Diversity, Indiana University 2013 MSW, Indiana University 2013 to 2016 Graduate Research Associate, College of Social Work, The Ohio State University 2016 to present Graduate Student Lecturer, College of Social Work, The Ohio State University 2016 to present Part-Time Faculty, School of Social Work, Wayne State University Publications Merritt, D.

Effective program models for the prevention of child maltreatment.), The APSAC Handbook on Child Maltreatment (4th ed. Los Angeles, CA: Sage. Parenting stress and child maltreatment: the buffering effect of neighborhood social service availability and accessibility. Children and Youth Services Review, 60(2016), 27-33.

Do social services matter for child maltreatment prevention?: Interactions between social support and parents’ knowledge of available local social services. Journal of Family Violence, 31(5), 557-565. Barriers to child maltreatment prevention programs for families involved with child protective services. Journal of Child Custody, 12(2), 152-174.

Fields of Study Major Field: Social Work viii Table of Contents Abstract. vi List of Tables. xiii List of Figures. 1 Statement of the Problem.

1 EABH Study Overview. 4 EABH Study Aims. 5 EABH Study Research Questions. 9 Overview of EABH Study Design and Analysis Plan.

9 Significance & Innovation of EABH Study. 10 Review of Literature & Theory. 13 Emerging Adulthood: Overview. 16 Feeling In-Between.

19 Emerging Adult College Students. 20 Emerging Adult Behavioral Health. 21 Emerging Adult Use of Behavioral Health Services. 30 Theoretical Frameworks: Emerging Adult Behavioral Health Study.

34 Theory of Emerging Adulthood. 34 Emerging Adulthood & Brain Development. 42 Andersen-Newman Model of Health Service Utilization. 51 EABH Study Hypotheses.

51 EABH Study Design. 54 The Healthy Minds Study. 55 EABH Study Sample. 56 EABH Study Variables.

77 Research Question One. 78 Research Question Two. 79 Research Questions Three & Four. 85 x Descriptive Statistics for Student-Level Variables.

85 Descriptive Statistics for Institution-Level Variables. 89 Main EABH Study Results. 92 Research Question One: Association between GPA & Service Use. 92 Research Question Two: Service Location & Behavioral Health Concerns.

96 Research Questions Three & Four: Student- and Institution-Level Predictors. 99 Hierarchical Generalized Linear Modeling (HGLM). 99 Logistic Empty Model. 100 Random Coefficients Model.

104 Logistic Contextual Model. 111 Summary of Results. 118 Discussion of Study Findings. 138 Implications of the Emerging Adult Behavioral Health (EABH) Study.

143 Limitations of the EABH Study. 160 Appendix A: Additional Neurodevelopmental Information. Mapping of Research Questions to Variables. Institutional Service Use.

Student Demographic Variables by Type of Behavioral Health Concern. 212 xii List of Tables Table 3. Sample size information. Help-seeking, service use, and behavioral health.

Service use by type of behavioral health concerns. Sample Demographic Characteristics. Institutional Level Descriptive Characteristics. Sample Descriptive Statistics for Institutional Variables.

Service use by GPA for students with mental health concerns. Service use by GPA for students with substance use concerns. Service use by GPA for students with co-occurring conditions. Logistic Regression Predicting Service Use based on GPA.

Service location by behavioral health concerns with post hoc results. Unit-Specific Model with Robust Standard Errors. Final Estimation of Variance Components. Random Coefficients Model under Restricted PQL (grand-mean centered)106 Table 4.

Random Coefficients Model Variance Components. Contextual Model under Restricted PQL (grand-mean centered). Developmental Differences Through a Biopsychosocial Lens (Bergman, Kelly, Nargiso, & McKowen, 2016). First Research Question & Variable Information.

Second Research Question & Variable Information. Third Research Question & Variable Information. Fourth Research Question & Variable Information. EABH Study: Institutional Characteristics.

Student Race/Ethnicity by Institution: Native Hawaiian. Student Race/Ethnicity by Institution: Hispanic/Latino(a)/Spanish Origin. Student Race/Ethnicity by Institution: Black/African American. Student Race/Ethnicity by Institution: White/Caucasian.

Student Race/Ethnicity by Institution: Asian/Asian American. Student Race/Ethnicity by Institution: Middle Eastern/Arab/Arab American. Student Race/Ethnicity by Institution: Pacific Islander. Student Race/Ethnicity by Institution: Other Race.

Prior Disability by Institution: ADHD. Prior Disability by Institution: Autism. Prior Disability by Institution: Brain Injury. Prior Disability by Institution: Chronic Illness or Health Condition.

Prior Disability by Institution: Deafness or Hearing Loss. Prior Disability by Institution: Learning Disability. Prior Disability by Institution: Mobility/Orthopedic Disability. Prior Disability by Institution: Psychological/Psychiatric Condition.

Prior Disability by Institution: Speech or Language Disorder. Prior Disability by Institution: Visual Impairment or Blindness. Prior Disability by Institution: Other Disability. Prior Behavioral Health Diagnosis by Institution: Depression.

Prior Behavioral Health Diagnosis by Institution: Anxiety. Prior Behavioral Health Diagnosis by Institution: Attention Disorder or Learning Disability. Prior Behavioral Health Diagnosis by Institution: Eating Disorder. Prior Behavioral Health Diagnosis by Institution: Psychosis.

Prior Behavioral Health Diagnosis by Institution: Personality Disorder. Prior Behavioral Health Diagnosis by Institution: Substance Abuse Disorder. Service Use by Behavioral Health Concerns for Each Institution. Demographic Variables for Students with No Behavioral Health Concerns 212 Table E.

Demographic Variables for Students with Mental Health Concerns. Demographic Variables for Students with Substance Use Concerns. Demographic Variables for Students with Co-Occurring Conditions. 218 xv List of Figures Figure 2.

Re-centering stages (Tanner, 2016). Model of Health Service Use with EABH study variables. Hierarchical nature of the EABH study sample. 56 xvi Introduction This chapter introduces the Emerging Adult Behavioral Health (EABH) study.

First, the chapter will provide background information about emerging adults, their behavioral health, and their use of behavioral health services. Following this is an overview of the current study, the specific aims, and research questions. The chapter ends with a brief discussion of the EABH study analysis plan. Statement of the Problem The emerging adult population consists of individuals between the ages of 18 and 29 years old.

As of 2016, this population has grown to 53.7 million in the United States (U.